Basic Information
| Provider Information | |||||||||
| NPI: | 1992819338 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRUNDY | ||||||||
| FirstName: | KIA | ||||||||
| MiddleName: | CALHOUN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 95000 LB# 7550 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191957550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443621735 | ||||||||
| FaxNumber: | 9732907495 | ||||||||
| Practice Location | |||||||||
| Address1: | 2333 MORRIS AVE | ||||||||
| Address2: | SUITE B18 | ||||||||
| City: | UNION | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070835714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9088108551 | ||||||||
| FaxNumber: | 9088108661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 02/12/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MA70103 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 8480907 | 05 | NJ | MEDICAID |